INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 10, 2012 to September 12, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Self Help Movement, Inc was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of the facility's administrative material and a personnel record, the facility failed to document supervision notes that include a reference to the charts of the clients that the counselor assistant counsels under close supervision demonstrating that at least one hour per week of direct observation is being conducted.
The findings include:
On September 10, 2012, the facility's administrative material and a personnel record requiring documentation of weekly supervision notes of the clinical supervisor giving direct observation to the counselor assistant were reviewed. Also, on September 10, 2012, the facility's administrative material and a personnel record requiring documentation of weekly supervision notes that include a reference to the charts that the counselor assistant counsels under close supervision demonstrating that at least one hour per week of direct observation is being conducted were reviewed. The facility did not provide documentation of supervision notes that included a reference to the charts of clients that the counselor assistant counsels under close supervision or the charts that are discussed with the counselor assistant demonstrating that at least one hour per week of direct observation is being conducted in one of one personnel record reviewed, specifically, personnel record # 9.
Employee # 9 was initially hired June 1, 2008 and was hired for his current position on April 29, 2009 and has a High School Diploma. The facility was required to provide documentation of supervision notes that included a reference to the charts of clients that the counselor assistant counsels under close supervision demonstrating that at least one hour per week of direct observation is being conducted. Personnel record # 9 included documentation of weekly supervision notes of the clinical supervisor providing direct observation with employee # 9 from 1/3/12 to 9/11/12. However, all of the supervision notes did not include a reference to the charts of clients that employee # 9 counsels under close supervision demonstrating that at least one hour per week of direct observation is being conducted.
The findings were confirmed during an interview with the director of administration on September 12, 2012 at approximately 3:00 P.M.
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Plan of Correction
An in-service training was held on September 28, 2012 for all clinical supervision, compliance and administrative personnel, highlighting the staff requirements of direct observation and close supervision of counselor assistants. The clinical supervisor will be responsible to include in supervision notes a reference to the charts of clients that the counselor assistant counsels or the charts that are discussed with the counselor assistant demonstrating that at least one hour per week of direct observation is being conducted. The human resources manager along with the compliance officer will ensure that the supervision notes containing the time and the proper documentation are placed in the counselor assistant's personnel folder.
This will be in compliance by October 8, 2012.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the personnel records and the facility's Staffing Requirements Facility Summary Report form, the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of STD/TB training within the first year of employment for counselors and counselor assistants and within two years of employment for all other staff.
The findings include:
On September 10, 2012 through September 12, 2012, four personnel records and the Staff Requirements Facility Summary Report form were reviewed to verify that employees had HIV/AIDS and STD/TB training within the first year of employment for counselors and counselor assistants and within two years of employment for all other staff. The facility failed ensure that staff persons received a minimum of 4 hours of STD/TB training within the first year of employment for counselors and counselor assistants and within two years of employment for all other staff in one of four records reviewed, specifically, record # 5.
Employee # 5 is a counselor and was hired on August 1, 2011. Employee # 5 would have been due to complete the STD/TB training by August 1, 2012; however, personnel record # 5 did not include documentation of STD/TB training as of September 12, 2012.
The findings were confirmed during an interview with the director of administration on September 12, 2012 at approximately 3:00 P.M.
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Plan of Correction
The employee's certificate was re-obtained on October 1, 2012 and a copy was placed in his personnel folder which states that he completed the STD/TB training on October 20th, 2005. The human resource manager and/or director of administration will be responsible for ensuring that all STD/TB and HIV/Aids trainings and certificates will be completed and in the personnel folder within the mandatory timeframe. |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on observations on September 12, 2012, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents.
The findings include:
A physical plant inspection was conducted on September 12, 2012. It was observed during the inspection at approximately 11:40 A.M., that the facility has two dumpsters near the rear parking lot. One of the dumpsters had two top lids and two side lids. The top right lid of the dumpster had a large crack in the middle, was bent in a downward position, and only partially covered the top right side of the dumpster. Also, half of the top left lid of the dumpster was missing, was bent in a downward position, and only partially covered the top left side of the dumpster. In addition, the bottom right side of the dumpster was uncovered because the bottom right side lid was open.
The findings were confirmed during an interview with the maintenance supervisor on September 12, 2012 at approximately 11:43 A.M.
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Plan of Correction
The director of building maintenance contacted the company for the dumpsters and had the lids replaced. A sign was placed near the dumpsters indicating the doors are to be kept closed at all times. The dumpsters' lids were replaced on September 18, 2012.
The director of maintenance will complete routine checks on the dumpsters to ensure the doors and lids are closed and the lids are in good condition.
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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on observations on September 12, 2012, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
The findings include:
A physical plant inspection was conducted on September 12, 2012. On September 12, 2012, 10 individual counseling offices and 8 group counseling offices were inspected. From approximately 10:30 A.M. to 11:30 A.M., it was observed that some of the individual counseling offices had a window in the middle of the front office door. The window would permit a person outside the individual counseling office to view the counseling sessions. The following are the individual counseling offices with a window in the middle of the front office door:
1) 3 individual counseling offices on the first floor located on the right side in the front counseling office section of the administrative area.
2) 4 individual counseling offices on the first floor located in the hallway of the middle rear counseling office section of the administrative area.
3) 1 individual counseling office on the first floor located in the hallway next to the conference room in the rear counseling office section of the administrative area.
4) 1 Individual counseling office on the first floor located next to the director of intake and community relations office of the administrative area.
The findings were confirmed during an interview with the one of the maintenance workers on September 12, 2012 at approximately 11:30 A.M.
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Plan of Correction
The director of building maintenance is in the process of overseeing the installation of mini-blinds over the windows of the doors for the counselors' offices. This will be completed by October 19, 2012. The clinical supervisor and/or the compliance officer will ensure that counseling sessions cannot be seen or heard outside the counseling offices on a daily basis. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on observations on September 12, 2012, the facility failed to ensure that heaters that are not permanently mounted or installed were not permitted in the facility.
The findings include:
A physical plant inspection was conducted on September 12, 2012. It was observed during the inspection at approximately 10:37 A.M., that there was a portable space heater in the counselor's office located at the side rear in the front counseling office section of the administrative area.
The findings were confirmed during an interview with one of the maintenance workers on September 12, 2012 at approximately 10:38 A.M.
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Plan of Correction
The director of maintenance removed the portable space heater from the counselor's office immediately.
The director of mainenance will inform all personnel by memo regarding the regulation pertainingto portable space heaters. He will also coduct routine checks of the building to ensure that heaters that are not permanently mounted or installed are not permitted into the building. This will be in compliance by September 26, 2012. |
705.10 (b) (6) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(6) Maintain all smoke detectors and fire alarms so that each person with a hearing impairment will be alerted in the event of a fire, if one or more residents or staff persons are not able to hear the smoke detector or fire alarm system.
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Observations
Based on observations on September 12, 2012, the facility failed to maintain all smoke detectors and fire alarms so that each person with a hearing impairment will be alerted in the event of a fire, if one or more residents or staff persons are not able to hear the smoke detector or fire alarm system.
The findings include:
A physical plant inspection was conducted on September 12, 2012. The bedrooms in the facility's inpatient non-hospital drug-free and inpatient non-hospital drug-free transitional sections were inspected to verify that the facility had a bedroom reserved in each sections with a smoke detector and fire alarm for a resident with a hearing impairment.
The facility had a bedroom reserved with a smoke detector and fire alarm for a resident with a hearing impairment in their in their inpatient non-hospital drug-free section of the facility. However, it was observed during the inspection from approximately 10:40 A.M. to 12:00 P.M., that the facility did not have a bedroom reserved with a smoke detector and fire alarm for a resident with a hearing impairment in their in their Inpatient non-hospital drug-free transitional section of the facility.
The findings were confirmed during an interview with the maintenance supervisor on September 12, 2012 at approximately 12:00 P.M.
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Plan of Correction
The director of building maintenance has contacted the fire alarm company to have a room equipped with strobe lighting in the transitional section of the facility. This room will be used for anyone that is hearing impaired. The director of maintenance will ensure that the fire alarm company completes this task and is in compliance by October 30, 2012.
The director of building maintenance will ensure that there is a bedroom reserved in both the inpatient non-hospital free and inpatient non-hospital drug-free transitional sections with a smoke detector and fire alarm for a resident with a hearing impairment. The director of intake will inform the director of building maintenance when a hearing impaired resident is being admitted into the inpatient portion of the program. The director of the transitional living facility will inform the director of building maintenance when a hearing impaired resident is being admitted into the transitional facility. This will ensure that a resident with a hearing impairment will have a bedroom that is equipped with strobe lights.
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill records, the facility failed to maintain a written fire drill record that included documentation of the problems encountered in the facility at the time of the drill.
The findings include:
Fire drill records were reviewed on September 12, 2012. The records were reviewed from the period covering August 2011 to September 2012. The facility did not have documentation nine of thirteen months reviewed, specifically, October 6, 2011; October 24, 2011; December 2, 2011; December 28, 2011; January 5, 2012; February 14, 2012; March 5, 2012; April 5, 2012; May 2, 2012; August 12, 2012, and September 10, 2012.
The findings were confirmed during an interview with the maintenance supervisor on September 12, 2012 at approximately 10:00 A.M.
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Plan of Correction
The director of building maintenance will meet with the resident managers to re-train them and emphasize the importance of filling out the fire drill logs completely and correctly. The fire drill logs will include documentation of problems encountered during the time of a fire drill. The resident manager on duty will be responsible for documenting the problems encountered during the time of a fire drill.
The director of building maintenance will conduct a review of the fire drill logs on a monthly basis to ensure compliance. Compliance will be achieved by October 31, 2012.
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on review of administrative documentation, the facility failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services at the end of the fiscal year.
The findings include:
The administrative documentation was reviewed on September 10, 2012. The facility was required to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services at the end of their fiscal year. The facility's 2010 through 2011 fiscal year ended on June 30, 2011. However, the facility's financial audit for this period was not completed until January 20, 2012.
The findings were confirmed during an interview with the director of administration on September 11, 2012 at approximately 3:00 P.M.
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Plan of Correction
The director of finance will ensure that compliance is achieved by making sure that the independent public accountant responsible for the annual audit has all information required and by keeping in touch by phone and e-mail with the accountant on a monthly basis. The chief financial officer in coordination with the director of finance will ensure that that compliance will be achieved by December 31, 2012.
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation that included an assessment of the client's assets/strengths, support systems, and coping mechanisms.
The findings include:
The facility's policy titled: "Biopsychosocial Assessment," states:
"Counselor's Assessment - This document is referred to as the integrated summary and includes strengths, weakness, problems areas and needs .....The integrated summary is an assessment of the bio-psychosocial and is due within 72 hours of client's admission."
On September 12, 2012, five records requiring documentation of a psychosocial evaluation were reviewed. The facility did not document a psychosocial evaluation that included an assessment of the client's assets/strengths, support systems, and coping mechanisms in two of five records reviewed, specifically, client records # 3 and 4.
Client # 3 was admitted June 19, 2012. The psychosocial evaluation was completed on June 23, 2012. However, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, and coping mechanisms.
Client # 4 was admitted June 26, 2012. The psychosocial evaluation was completed on June 29, 2012. However, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, and coping mechanisms.
The findings were confirmed during an interview with the director of administration on September 12, 2012 at approximately 3:00 P.M.
This is a repeat citation. The facility was cited on February 2, 2012 and August 24, 2011
for noncompliance with this standard.
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Plan of Correction
The clinical supervisor and compliance officer provided training on 9/25/12, regarding the assessment of the client's assets/strengths, support systems, coping mechanisms and attitude towards treatment on the integrated summary which is Self Help Movement's assessment document of the psychosocial evaluation. The clinical supervisor and compliance officer will facilitate future staff trainings regarding this assessment to ensure implementation and compliance. Compliance shall be achieved by October 1, 2012.
The compliance officer and/or clinical supervisor will monitor the psychosocial evaluations on a weekly basis to make sure the evaluations are documented on time and include an assessment of the client's assets/strengths, support systems, and coping mechanisms.
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709.53(a)(12) LICENSURE Work as treatment
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to verify that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
The findings include:
On September 12, 2012, seven client records requiring documentation for verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan. The facility did not document verification of work therapy in the comprehensive treatment plan or treatment plan updates in six of seven records reviewed, specifically, client records # 1, 3, 4, 5, 6, and 7.
Client # 1 was admitted May 26, 2012. The comprehensive treatment plan was completed June 9, 2012 and the treatment plan updates were completed June 25, 2012; July 25, 2012; and August 25, 2012. The facility was required to document work therapy on the comprehensive treatment plan and treatment plan updates. However, client record # 1 did not include documentation of work therapy in the comprehensive treatment plan and treatment plan updates as of September 12, 2012.
Client # 3 was admitted June 19, 2012. The comprehensive treatment plan was completed July 3, 2012 and the treatment plan updates were completed July 19, 2012 and August 19, 2012. The facility was required to document work therapy on the comprehensive treatment plan and treatment plan updates. However, client record # 3 did not include documentation of work therapy in the comprehensive treatment plan and treatment plan updates as of September 12, 2012.
Client # 4 was admitted June 26, 2012. The comprehensive treatment plan was completed July 26, 2012 and the treatment plan update was completed August 26, 2012. The facility was required to document work therapy on the comprehensive treatment plan and treatment plan update. However, client record # 4 did not include documentation of work therapy in the comprehensive treatment plan and treatment plan updates as of September 12, 2012.
Client # 5 was admitted June 11, 2012. The comprehensive treatment plan was completed June 25, 2012 and the treatment plan updates were completed July 11, 2012 and August 11, 2012. The facility was required to document work therapy on the comprehensive treatment plan and treatment plan updates. However, client record # 5 did not include documentation of work therapy in the comprehensive treatment plan and treatment plan updates as of September 12, 2012.
Client # 6 was admitted July 3, 2012. The comprehensive treatment plan was completed July 14, 2012 and the treatment plan updates were completed August 2, 2012 and September 3, 2012. The facility was required to document work therapy on the comprehensive treatment plan and treatment plan updates. However, client record # 6 did not include documentation of work therapy in the comprehensive treatment plan and treatment plan updates as of September 12, 2012.
Client # 7 was admitted June 26, 2012. The comprehensive treatment plan was completed July 10, 2012 and the treatment plan updates were completed July 26, 2012 and August 25, 2012. The facility was required to document work therapy on the comprehensive treatment plan and treatment plan updates. However, client record # 7 did not include documentation of work therapy in the comprehensive treatment plan and treatment plan updates as of September 12, 2012.
The findings were confirmed during an interview with the director of administration on September 12, 2012 at approximately 3:00 P.M.
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Plan of Correction
The clinical supervisor and compliance officer provided training on 9/25/12, regarding the documentation of work therapy on the treatment plans. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan. The counselor will be responsible for including work therapy on the treatment plans. The clinical supervisor and/or the compliance officer will be responsible for monitoring the treatment plans and ensuring that they are completed with the proper information on a weekly basis. The clinical supervisor will ensure compliance when signing off on the treatment plan. This shall be in compliance by October 1, 2012 |
709.71(b)(4) LICENSURE Consent to Residency
709.71. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to residency.
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Observations
Based on a review of client records, the facility failed to document a date the consent to residency form was signed by the client and/or ensure the client sign the consent to residency form.
The findings include:
On September 12, 2012, five client records requiring documentation of a consent to residency were reviewed. The facility did not document a date the consent to residency form was signed by the client in two of five records reviewed, specifically, client records # 1 and 5. Also, the facility did not ensure the client sign the consent to residency form in two of four records, specifically, client records # 1 and 5.
Client # 1 was admitted on February 15, 2012 and the client signed the consent to residency form. The consent to residency form was due to be signed by client # 1 upon admission by February 15, 2012. However, client record # 1 did not include documentation when the consent to residency was signed by client # 1 as of September 12, 2012.
Client # 5 was admitted on March 9, 2012. The consent to residency form was due to be signed by client # 1 upon admission by March 9, 2012. However, client record # 5 did not include documentation of a signature from client # 5 on the consent to residence form as of September 12, 2012.
The findings were confirmed during an interview with the maintenance supervisor on September 12, 2012 at approximately 3:00 P.M.
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Plan of Correction
The director of intake conducted an in-service training with intake coordinators to discuss the requirements to document the date the consent of residency form was signed and/or ensure the client signs the consent to residency form.
The director of transitional living facility conducted an in-service training with the transitional supervisor to discuss the requirements to document the date the consent of residency form was signed and/or ensure the resident signs the consent to residency form. This shall be in compliance by October 8, 2012. The compliance officer and the director of transitional living will ensure compliance by conducting audits of the charts on a monthly basis.
Client records #1 and #5 cannot be signed because the clients have already left the program. |